Patient Autonomy

When I was in clinic today, my preceptor (Dr. M) told me about a patient he saw last week. An 86 year old man came into the office with his son and daughter because of altered mental status. His children reported he has been getting progressively more confused and the patient could barely stay alert during the office visit. At one point, they had given him coffee to try and help him stay awake, and he felt asleep holding the coffee, ending up spilling it on himself.

Altered mental status in an older patient is never a good sign, so Dr. M discussed going to the emergency room with the family. The patient was insistent that he didn't want anything done to him and he certainly didn't want to go to the emergency room. Dr. M and the family compromised and decided to do blood work in the office that day and set up an appointment to get a CT scan the next morning (to rule out stroke, etc...)

The blood work came back the next morning with HUGELY elevated liver enzymes and some other minor elevated electrolytes. Dr. M immediately called the daughter to advise them once again to go the hospital. He even arranged for a hospitalist to admit them directly, so they wouldn't have to wait in the ER. The daughter said the previous night had not gone well, so she would discuss it with her brother and father. She later called Dr. M back that day to tell him her father had passed away, not wanting to go to the hospital.

This story bothered me. At the core of it, lies the issue of medical ethics. One of the four pillars of medical ethics is patient autonomy -- you can't make a patient do something they don't want to do, but as their doctor, you feel a certain level of responsibility for their well being. So what do you do? Can you force someone to go the ER? If someone has resigned themselves to death, but you know there is an easy way to save them, do you just let them die? I think it's one of the bigger lessons in medicine that I'll have to learn -- to accept that you can't control everything, sometimes it's the disease and other times it's the patient's will.